Proton therapy treatment for throat cancer

MD Anderson Cancer Center
Date: 04-14-2014

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Lisa Garvin: Welcome to Cancer News Line, a podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today our guest is Dr. Steven Frank. He is the newly appointed Medical Director of MD Anderson’s Proton Therapy Center. And we're here to talk about treating head and neck cancers with proton therapy. So, Dr. Frank, we've recently introduced a service line to treat head and neck cancers at Proton Therapy. How did that come about?

Dr. Steven Frank: Well, this has been in development for several years. And what we have seen as a growing need is for patients really that have started to develop what we call HPV-associated oropharynx cancers. And these are cancers that are generally in the base of tongue or in the tonsils. And it's been really a rising epidemic in this country. For these patients we've also see that these HPV-associated tumors are highly curable. And therefore the typical side effects that patients are going to experience, they will live with not only during the course of their treatment but for a potentially 30 to 50 years after the treatment. And typically these are young patients with young families that want to continue to work during their treatment and afterwards. The novel development that has happened here at MD Anderson is that we have been able to harness a proton technology in a way that's really never been done before. We are using intensity modulated proton therapy, and this is the first technology that has been allowed to really treat the entire head and neck region in ways that we've been utilizing standard radiation therapy. The advantages have been recently demonstrated in some data that we have been able to identify patients in oropharynx with a 50% reduction of feeding tubes. And by incorporating protons into this treatment we are able to eliminate and reduce the dose to the brain stem, to the oral cavity, the salivary glands, thereby helping patients make it through their treatment with less toxic side effects. And also minimize the burden of toxicity following treatment. And so the advantage of this is really exciting because we didn't just see this in oropharynx, we have recently just seen this in nasopharynx too. And nasopharynx is another, it's an EBV-associated disease that is very much endemic in the Asian populations. And we've seen a 60% reduction in feeding tubes in these patients with IMPT or proton therapy. Both of these have really spurred the development of clinical trials here at MD Anderson. And that clinical trial is a Phase II, Phase III randomized trial that has allowed us to now look at this in a very concerted fashion to be able to potentially standard of care for the treatment of head and neck malignancies.

Lisa Garvin: If we could take a step back because some of our viewers may not know the acronym HPV. As we know it's the human papilloma virus, which is generally a sexually transmitted disease. What is the role of HPV in the oropharynx and nasopharynx cancers?

Dr. Steven Frank: Well, for what we're seeing is that HPV is usually acquired in a younger age and has a latency period that can last up to 20 to 30 years. Then the tumor is activated or the cells, the virus infiltrates, and allows an activation that causes tumor cells to continue to divide. And so whereas there are normal mechanisms of preventing the tumor from dividing, these cells initiate a cascading of events that drive the cells to become invasive and then become in itself malignant.

Lisa Garvin: And you also mentioned EBV. That's the Epstein Barr Virus that also has a role in head and neck cancers?

Dr. Steven Frank: It does. And it is more predominant in nasopharynx cancers. And, again, this is more endemic into the Asian populations that we see.

Lisa Garvin: Have you found out why these incidences are rising?

Dr. Steven Frank: Well, we are investigating that. I think we don't fully have all of the information yet as to why there is such a high risk and high rise of patients with HPV, but it's an active area of investigation here at MD Anderson.

Lisa Garvin: I'm guessing that, of course the nasopharynx is the area right about nose level, and then the oropharynx would be right behind the tongue. It seems to me that effects to physical function and also appearance would probably be pretty high with standard treatment.

Dr. Steven Frank: Well, standard treatment has multiple side effects. It caused patients to have a loss of taste. It can cause patients to have dry mouth. It can cause patients to have nausea and vomiting that requires emergency room visits, hospitalization, the ability and necessity for IV hydration on a daily basis or weekly basis. It causes a significant amount of pain by having ulcers in the mouth, which require narcotics. So there are a lot of side effects that taken all together really decrease the enthusiasm of patients to wanting to eat, drink, and maintain their weight. And so it causes additional fatigue and depression that if we can decrease those side effects which is where proton therapy has a place, if we can minimize those side effects during the course of treatment, then patients can make it through their treatment while being able to continue to work which is our goal and to continue to work immediately after treatment to live more prospered lives with excellent quality of life.

Lisa Garvin: I was always led to believe that head and neck cancers were typically a surgical disease. Obviously we are moving away from that, but are today's standard treatments more surgical in nature and maybe radiation therapy as the follow up? Or?

Dr. Steven Frank: For certain disease sites in the head and neck surgery is the frontline. For certain diseases in the head and neck, radiation is the front line. Radiation with or without chemotherapy. And in general we work as a multi-disciplinary team where patients see a surgeon, a medical oncologist, and radiation oncologist, and we discuss these patients at our multi-disciplinary conference every week and make standard recommendations for standard of care. So for the oropharynx and the nasopharynx, generally these are radiation primary diseases. The advancement of trans oral resection in early stage is something that is being actively investigated here. But here's an area to have proton in therapy, and radiation therapy has really been the standard of care for the last several decades.

Lisa Garvin: And so we, I understand that MD Anderson is kind of at the forefront of using proton to treat head and neck cancers.

Dr. Steven Frank: That is correct. Within the last three years, again, we've been able to harness proton technology in a very unique way by using what we call a scanning beam or pencil beam, which allows you to deliver radiation in very unique spots. That has allowed us to harness the technology and deliver it in a way that has never been delivered before in the sense of treating are these headache tumors. So it's a unique technology. If you look at the future of radiation all the new proton centers coming online will all come online with this technology. And so we've had the opportunity to evaluate it, develop it, and translate it into our clinical practice. And now we're starting to see the benefits of this technology in our patients.

Lisa Garvin: This is still protocol-based at this point?

Dr. Steven Frank: Correct. Generally, all of our patients treated at the Proton Center are under protocol. We're looking at these. We are getting perspective, quality of life metrics on every single patient so that we can communicate the value because ultimately it is important for us with any advancement of any technology to be able to define the value of that technology to be able to communicate in terms of there might be some more added expense in new technology. However, if the overall episodic cost of care is actually lower and the outcomes are better, then it provides a high value proposition. And this is where I see and we see proton therapy for head and neck malignancies.

Lisa Garvin: How many patients have you been able to treat? Have you accrued much data yet with using this for head and neck?

Dr. Steven Frank: We've treated approximately 200 patients in head and neck over the last three years with proton therapy. And what it has allowed us to do over that time is to treat every specific disease site within a head and neck and formulate these standard protocols and these randomized trials to ask these very important questions. It's a very narrow window where we can ask these questions where we don't know the answer. So it's important for us to do this prospectively and communicate the value to the community.

Lisa Garvin: What kinds of research paths are you taking with this technology?

Dr. Steven Frank: We're looking at everything from peri-orbital tumors, tumors that have standardly been treated with surgery and inoculation. We've got an amazing head and neck eye and occu-plastic groups under the leadership of Bita Esmaeli who, Dr. Bita Esmaeli, who really has pioneered the concept of orbit sparing approaches. And with that, proton therapy is a huge advantage because if we can minimize dose to the cornea, to the optic nerves, to the optic apparatus, patients can be potentially cured of this disease without affecting their vision. And so that is a very exciting opportunity that we are seeing with proton therapy. Additionally we are seeing, as we have discussed, with nasopharynx, with oropharynx. We're also seeing this with base of skull tumors. And this is very important because this is where radiation can be more commonly in the brain. And if we can eliminate that dose to the brain we can help minimize some additional side effects such as brain damage and fatigue and nausea and vomiting that commonly occur to patients who have radiation in the skull base areas. So there's a novel skull based program under the leadership of Dr. Ehab Hanna who has really been pioneering the skull base program here. And so, again, it just speaks to the fact that we really work as multi-disciplinary teams. And this is just one component of that.

Lisa Garvin: Well, it seems like proton and head and neck cancers would be a good pairing because you are working in tight corridors with very critical structures nearby. I guess my question is, we've been open since 2006, why did it take us this long to move to the head and neck arena with proton treatment?

Dr. Steven Frank: Yes, it is an interesting story because as we look over the last, you know, seven years I have been working to develop this. And we had made a very concerted effort not to treat patients with anything that was less quality than our current standard of care. So over the first several years, passive scattering, which is more of the standard historic proton therapy delivery over the last several decades, had been our standard. And it took us until 2010 to be able to start to use active scanning beam. And that's when, as I reviewed and looked at all of the treatments, nothing had beaten our standard radiation therapy delivery. And it wasn't until 2010, a young 33-year-old female who came here with a base of skull tumor in the nasopharynx that was wrapping around her brain stem, and she had no other option to get treated other than no treatment at all. She was not a surgical candidate. And nobody with IMRT would treat her. So we sat down. We had just gone through all the planning with the quality assurance processes, and I reviewed it with her and her family the opportunity for proton therapy with intensity modulated proton therapy or with a standard IMRT. With the standard IMRT I would have caused too much damage to her brain stem, which was unacceptable. So she and her family discussed it, and they were willing to consider it. And with concurrent chemotherapy under the care of Dr. Merrill Kies here, we were able to treat her, and three years later she has no evidence of disease. She has three young children, and she recently sent us a picture showing her and this is a dramatic, you know, advancement that really defines the hope of proton therapy.

Lisa Garvin: So what would your advice be to people who have been diagnosed with head and neck cancer? They may not now that proton therapy is an option. Should they ask, so if their doctors are, how would they go about seeking information?

Dr. Steven Frank: I think if they are interested in considering proton therapy, which is a novel new treatment to contact us directly. Contact, either they can go online; they can contact MD Anderson, the MD Anderson Proton Center and ask for a consultation, a second opinion. We will then look, have them be seen in our multi-disciplinary environment with our head and neck surgeons, medical oncologists, and myself or anyone else on our head and neck radiation team, and we will go ahead and make an assessment whether proton therapy is something that would be appropriate for them. We have several protocols, which are opportunities to evaluate whether proton therapy is the right treatment option for them. But I think it's a very exciting, it's a very new technology, and it's one that has the potential to become a standard of care down the road.

Lisa Garvin: Thank you Dr. Frank. It sounds like we're poised to really make a difference with head and neck cancers in proton therapy.

Dr. Steven Frank: Thank you. It has been great to be here Lisa. I really appreciate the opportunity.

Lisa Garvin: If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789 or online at MDAnderson.org/ask. Thank you for listening to this episode of Cancer News line. Tune in for the next podcast in our series.